Presenting the Case for Cybersecurity Education of Clinicians

Session 149; February 13, 2019

Axel Wirth, CPHIMS, CISSP, HCISPP

Distinguished Technical Architect, Symantec Corporation

Joseph H. Schneider, MD, MBA

Assistant Professor, University of Texas Southwestern, Dallas

Joseph H Schneider, MD, MBA has no real or apparent conflicts of

interest to report.

Axel Wirth, CPHIMS, CISSP, HCISPP is employed by Symantec, a

cybersecurity vendor, but has no real or apparent conflicts of interest

to report.

Conflict of Interest

• Discuss the complexities of today’s cybersecurity challenges and

how they impact healthcare organizations on many levels

• Define the cybersecurity responsibilities, and consequently

educational needs, of non-technical stakeholders

• Analyze clinicians’ role in today’s cybersecurity environment,

ranging from patient care decisions to incident response

• Axel will present first, followed by Dr. Joe

Learning Objectives & Agenda

Session sponsored by HIMSS

Collaborator: American College of

Clinical Engineering (ACCE)

Healthcare Cybersecurity

A Growing Risk – But Why and Why Now?

Threats

Vulnera-

bilities

Assets

Today’s Threats:

• Actors: Cyber-Criminals,

Cyber-Activists, Nation States,

Hackers for Hire

• Motivation:

Financial, Political, Economic

• Attacks:

Targeted, Sophisticated,

Stealthy, Well-Executed

Vulnerabilities:

• Growing Attack Surface

• Increasing Complexity:

ACO’s, EHR Adoption, Home Care,

Medical Device Networks,

• Integration creates:

Dependency, Single Points of Failure

• Technology adoption:

Cloud, Mobile, IoT, AI, Blockchain, ….

Assets:

• Traditional: Information, Money, Identities

• Evolving: Infrastructure, Society, Economy

• Indirect: Care Delivery, Patient Safety,

National Security

Growing

Cyber-Risks

Changing

Motivation

Higher

Impact Potential

Cybersecurity in 2019

Know Thy Enemy – What They are After

• Cybercrime as a Business / Cybercrime impacting Business

• Underground Economy: ~$1.5 Tn annual profit (Dr. M. McGuire: U of Surrey)

• Global economic losses estimated to be ~$1-3 Tn (range of a few % of GDP)

• Cyber Warfare and Activism

• Attacks as a political statement - Anonymous hacktivists group attacked

Boston Children’s Hospital (2014) & Hurley Medical Center (2016, Flint, MI)

• Intellectual Property

• Clinical trials, research, designs, formularies, software code, …

• Attacks may or may not be targeted

• Victim simply may fit exploit profile

• Or, may be looking for easy prey

and healthcare may fit the bill

• Insider Threats

• ID Theft, Negligence, …. Patients

Cybersecurity in 2019

Know Thy Enemy – Many Opportunities

https://www.wired.com/story/notpetya-cyberattack-ukraine-russia-code-

crashed-the-world/

https://news.sky.com/story/cyber-extortionists-the-dark-overlord-offering-

celeb-plastic-surgery-photos-11597618/

Attack Complexity and Impact

Many Opportunities to Monetize

Cybersecurity in 2019

Value of Health Data in the Underground Economy – Myths

“On the black Market, your Health

Records is worth $50, compared to

$1 for a Credit Card Number”

(still widely quoted in 2018)

FBI Private Industry

Notification (April 2014)

“… $1 for SSN or CCN”

RSA Whitepaper

(July 2013)

“… $1 for SSN”

Electronic Health Reporter

(Jan. 2013)

“… $14-18 for CCN, $1 for SSN”

Research by

World Privacy

Forum

IDExperts

(Feb. 2012)

“… $1 for SSN”

Cybersecurity in 2019

Today’s Reality is Far More Complex

From a few $’s to $1,000 …

to free …

… to unquantifiable.

Healthcare Cybersecurity – What is Different?

A Cybersecurity Expert’s View

• (although that is a pretty low bar to clear - Target, Equifax, Marriott, etc.)

• Healthcare: ¾ of hospitals spend <6% of their IT budget on security

• Security mature industries spend 10% - 12% of IT budget

Healthcare is viewed as less Security Mature than other Industries

• Complexity is your enemy – and healthcare is quite complex:

• Organizational – impact on decision making and enforcement

• Technical – number of vendors, devices, platforms, etc.

• Employment status, workflows, and equipment needs:

• Contracted vs. employed

• Changing roles & privileges, shared accounts, mobility, etc.

• Difficulty of enforcing security and compliance:

• Strict enforcement can impact care delivery

• Maintenance challenges (patching) and legacy devices

BUT - Enforcing Security is more difficult than Elsewhere

What HIPAA Taught Us

Confidentiality, Integrity, Availability – Really?

• HIPAA trained us well: C – I – A (e.g., Breach Notification Rule)

• Shifting Global Threats are leading to changing Security Priorities:

• From accidental incidents to targeted and malicious attacks

• Changing motivation: criminal attacks, political objectives

• Complex objectives and targets: devices, information, trust

Confidentiality Availability Integrity

Past Negligence, or lost or stolen devices Technical failure Accidental alteration of data

Now

• Skilled adversaries with a mission

• Criminal intent (ransom, blackmail)

• Political attacks (nations, hacktivists)

Care delivery, e.g.:

• Ransomware

• Medical Devices

• Targeted attacks: intent to harm

• Create doubt in data (and larger

healthcare system)

Lesson learned: Compliance does not guarantee sufficient Security

"Compliance only works if your enemy is the compliance auditor“

Ted Harrington, Independent Security Evaluators

Security Scenarios – Example 1

“I see the Cloud from Both Sides Now”

• Controlled (e.g., EHR migration) – compliance and security should be part of the

design process and architecture

• Uncontrolled (e.g., file sharing) – this is the more difficult one to address; plenty of

security, privacy, and compliance risks

Understanding Cloud Adoption – and Security Implications

• Technologies at play (adopted for the cloud use case):

• Network security (data in motion)

• Endpoint security (data at rest, e.g. cloud workloads)

• Encryption (at rest and in motion)

• Data Loss Prevention (at rest and in motion)

• CASB (Cloud Access and Security Broker) – works with or includes several of the above

• How do you protect data that doesn’t even traverse your enterprise?

• Controlling and securing cloud-to-cloud traffic

• 5G is around the corner and will make this even worse

Need to Assure Confidentiality, Integrity, Availability in Both Scenarios

Security Scenarios – Example 2

Medical Device Cybersecurity

• Patient Safety – plenty of security research but no reported case of patient harm

• But feasible and plausible – no need to panic, but proceed with a sense of urgency

• Care Delivery – many reported, e.g. CathLab shutdown; WannaCry (UK NHS)

• Device as the weakest link – reported beachhead attacks

• Other risks: privacy, reputation, financial

• Likely scenario – incident resulting from a non-targeted event

What are the Risks?

• FDA Pre and Post Market Cybersecurity Guidance

• Developing efforts in China, Canada, EU

• Healthcare Providers are launching Cybersecurity Initiatives

• Device Manufacturers developing Security Strategy and Expertise

• Stakeholder cooperation – e.g. vulnerability sharing

Industry and Regulatory Action

• Insufficient for medical devices:

• Consider non-PHI risks:

• data not attributed to specific or identifiable patients

• technical device data (calibration, safety limits …)

Note: HIPAA C-I-A limited to PHI

Healthcare Cybersecurity - Recap

Why are Health Organizations and Data a Target?

 Rich information

 Longtime value

 Perceived low defenses

 Many entry points

 Many ways to monetize

 Valuable Intellectual Property:

• Competitive advantage

• Economic differentiator

 Pressure to restore operations (Ransomware)

 Difficult and slow to monetize

 Utilization requires skill and patience

 Saturated underground market

 (Moral concerns)

Attractors

Detractors

Healthcare Cybersecurity - Recap

Clinician Cybersecurity Leadership

• Security Strategy and Governance

• Procurement Decisions

• Replacement Planning

• Education

• Peer Leadership

• Public Face / Communication

• Patient Advisory and Advocacy

• Security Incident Response

• Security Research

Enablement

Role

Public Role

Security Role

Administrative

Role

As adversaries change, our cyber defenses needs to adopt, too.

Remember – Minutemen used to work well … but not anymore.

Limited incentives

for vendors/device

makers to make

incidents public

Healthcare CIOs

can’t keep up with

patching

No central

repository for

vulnerabilities and

incident reporting

Executives, lawyers

& compliance

poorly understand

cyber-risks

Clinicians generally

don’t appreciate

risks

Limited awareness

of security impact

on safety and

efficiency

Cybersecurity Is Like Herding Cats…

A Clinician and Informaticist’s View

A Quick View of How Clinicians Deal with

Cybersecurity –

At Least Enough to Cause Problems…

• 123456

• password

• 123456789

• 12345678

• 12345

• 111111

• 1234567

• sunshine

• qwerty

• iloveyou

We Use The Weakest Passwords

…That We Can

We Write Passwords Down

… As They Become Harder to Memorize

We Share Our Passwords

… Especially When “Locked Out”

We Click Through Online Training

… As Quickly as We Can to Get Through it

We Text & e-mail PHI Regularly

… Because Secure Systems are Hard to Use

• Cybersecurity is “not my job”

• Annual security training classes or programs are a waste of time

• IT/Biomed is more concerned with eliminating all risk rather than

balancing it with patient safety

• IT/Biomed doesn’t understand the challenges they create

• We doubt that we can be protected

Enough Clinicians Feel That…

(At Least Enough to Be a Big Problem)

• We highly value patient safety

• We highly value efficiency (e.g., 40% of healthcare workers would

allow a colleague to use their work computer)

• Our education and organizations generally don’t support

connecting cyberrisk with patient safety/efficiency

• Like adolescents, we undervalue risks that aren’t apparent

• Our informatics leaders (CMIOs) are not focused on cybersecurity

Clinicians Undervalue Cyberrisk Prevention

Some Hypotheses Why This is so:

What CMIOs Focus On

2008 and 2014

What CMIOs Focused On In 2017

Cybersecurity is Still Not on the Radar

• Abbott/Chertoff 2018 study of 300 physicians:

• 92% - keeping data secure is a focus of their hospital

• 71% - cybersecurity is a shared responsibility

• 75% - feel ill-prepared to mitigate cyber risks

• Only 15% report having seen or read advisories related to

medical device security in the last six months

• Report recommendations:

• Create standards and cybersecurity by design

• Invest in cybersecurity incident response processes

• “Improve education, focus & training to increase all

stake-holders' understanding of cyber risk...”

Some Physicians Want To Help

There is Hope

Cybersecurity Task

Force Report

1. Define and streamline cybersecurity leadership, governance,

and expectations

2. Identify strategies to protect R&D efforts and intellectual property

from attacks or exposure

3. Improve information sharing of industry threats, weaknesses,

and mitigations

4. Improve staffing necessary to prioritize and ensure cybersecurity

awareness and technical capabilities

5. Increase cybersecurity awareness and education

6. Increase security & resilience of medical devices and health IT

HHS: Cybersecurity Is Public Health Issue

Task Force Recommended Goals

– Position cybersecurity as part of patient safety & effectiveness

– Focus on identifying and reducing cybersecurity “hassles”

– Make education a “painless” daily thing, not an “annual

competence” and reward risk identification

– Provide support for CMIOs and other clinicians to help IT/Biomed

– Support trained clinicians as equal partners in the cybersecurity

decision-making process

– Consider cybersecurity misbehavior as the equivalent of

providing bad clinical care, not an administrative infraction

What Would A Better Culture Look Like?

Organizational & Clinical Leaders Could…

Add Clinicians To Cybersecurity Leadership

Axel Wirth’s Proposed Framework

• Security Strategy and Governance

• Procurement Decisions

• Replacement Planning

• Education

• Peer Leadership

• Public Face / Communication

• Patient Advisory and Advocacy

• Security Incident Response

• Security Research

Enablement

Role

Public Role

Security Role

Administrative

Role

Add Clinicians To Cybersecurity Leadership

The Story of Dr. RK

• Security Strategy and Governance

• Procurement Decisions

• Replacement Planning

Administrative

Role

• Dr. RK, an interventional cardiologist, became frustrated with the

seemingly arbitrary “rules” imposed on clinicians by IT Security

• CMIO worked with CIO for Dr. RK to co-chair the “Clinical Data

Access Team (CDAT)” that handled privacy & security decisions

• Dr. RK took shared responsibility for issues that impacted clinical

care, delivered tough cybersecurity messages to physicians and

stood side-by-side with IT Security and Biomed

• Compensated at ~ 40% of earnings, but it was adequate

• Dramatically improved perceived quality of security decisions and

the relationship of IT Security with other clinicians

Add Clinicians To Cybersecurity Leadership

The Story of Dr. DM

• Dr. DM, an OB/GYN, became frustrated with the “unfriendliness” of

HIT training and messaging for physicians

• CMIO worked with the Education VP to get Dr. DM onto HIT

Education Team

• With Dr. DM’s support, the team built simple and effective

education tools, especially videos of physicians speaking to

physicians

• Compensated at ~ 40% of earnings, but it was adequate

• Dramatically improved the quality of HIT education and the

relationship of the Education Team with clinicians

• Education

• Peer Leadership

Enablement

Role

Add Clinicians To Cybersecurity Leadership

Other Things Clinicians Like Dr. DM can do:

• Find the patient safety impacts of all proposed cybersecurity

changes/announcements

• Construct the best messaging and methods to “catch” the

clinician’s focus (it’s not e-mail)

• Build cybersecurity education into the clinician’s regular activities

• Construct meaningful reward programs for reporting cybersecurity

weaknesses

• Build rapport by referring to physicians, nurse practitioners &

physician assistants by their titles (or as “clinicians”) rather than as

“providers” or ”mid-levels”

• Education

• Peer Leadership

Enablement

Role

• Is self-directed & they are ready

• Is from experience

• Addresses “real” situations

• Can be applied quickly

Doctors and Clinicians Learn As Adults

They Learn Best when Learning:

Add Clinicians To Cybersecurity Leadership

Clinicians are Your Best Representatives

• Cybersecurity is increasingly impacting patients (e.g., pacemaker

recall over security issue)

• Physicians typically are having discussions with patients about

their care and should begin to bring cybersecurity into these

• Physician/clinician informatics groups (e.g., AMIA, AMDIS,

professional organizations) can prepare national positions where

appropriate

• The Dr. RKs and DMs can help with local messaging

• Having patients represented in cybersecurity decision-making is a

next step

• Public Face / Communication

• Patient Advisory and Advocacy

Public Role

Add Clinicians To Cybersecurity Leadership

Other Things Clinicians Like Dr. RK can do:

• Security Incident Response

• Security Research

Security Role

• Lead root cause analyses regarding cybersecurity/patient safety

issues, preferably handled in the Patient Safety Organization

• Work with IT/Biomed in managing incidents to help them

understand the impact of proposed actions

• Serve as the co-spokesperson during cybersecurity incidents

• Identify weaknesses

• Construct protected time for IT/Biomed staff to join clinical rounds

with physicians, nurses, NPs, etc. to understand their workflow

and the importance of rapid and easy data access

• Connect with CIOs/CISOs and let them know we value cyber-security

• Lobby for funding for cyber-clinicians – the Dr. RKs/DMs

• Encourage AMDIS, AMIA, ANIA and other clinical informatics

organizations to engage with national programs, with educational

materials (e.g., how to work with your CISO) and speakers

• Engage professional clinical/medical societies both nationally (e.g., the

ANA, AAP) and locally (e.g., the Texas Medical Association)

• Have your CEO/COO/CMO/CNO provide medical staff/nursing

recognition to clinical cyber-security leaders

CMIOs Need To Focus On Cybersecurity Too

Things CMIOs can do:

• These physicians/clinicians are not unique

• Often “too busy”/too scared (?) to step forward if not encouraged

• Issues to consider:

– How do you find them?

– What do you want them to do (domain versus local experts)

– How do you compensate them?

– How do you build their competence?

– How do you measure their success?

– How do you build their reputation in the organization?

– What is their career path?

Identifying Clinical Cybersecurity Leaders

But – Takes Work to Develop Them

Dr. Joe Schneider, drjoes1tx@gmail.com

Axel Wirth, axel_wirth@symantec.com

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